Malnutrition

Malnutrition is categorized into the short term response of wasting (weight for height ratios) and the long term response of stunting (height for age and sex ratios) using standard scores. Weight for age ratios makes no distinction between the short and long term effects. Traditionally it has been classified into marasmus, kwashiorkor, and marasmic kwashiorkor.

Marasmus

This is a mixed deficiency of both protein and calories, resulting in non-oedematous malnutrition. Decreased weight for age and sex ratios (<60% of the mean).

• Hunger, listless, emaciated child
• Loose, wrinkled skin, 'old man' appearance, decreased skin turgor
• Muscle atrophy and little subcutaneous fat
• Thin sparse hair, hair color changes unusual
• Hypothermia, bradycardia, hypotension ( basal metabolic rate decreases)

Kwashiorkor

This results in edema which is due to an unknown cause, although it has historically been attributed to a disproportionately low protein intake compared with calorie intake. There is a near-normal weight for age ratio (weight for age and sex ratio <80%) and edema.

• Lethargic, miserable, no appetite
• Edema: Hypoalbuminaemic, overall 'fatness' appearance, moon face
• Hepatomegaly (fatty infiltration)
• Cardiomegaly
• Thin, red hair and darkened skin
• Skin lesion (flaking paint rash, ulcers, fissures, pellagra-type rash)
• Infections, secondary immunodeficiency.

Marasmic Kwashiorkor (mixed type)

A combined type exists where there are features of both marasmus and kwashiorkor, with a weight for age and sex ratio of <60% with edema.

Management

1. Initial rehydration with oral rehydration salt solution or IV fluids if in shock.
2. Dilute milk for 5 days, increasing volume gradually to 150 ml/kg/day. Look for and treat hypoglycemia, hypothermia, electrolyte imbalance, micronutrient deficiencies, and infection.
3. High-energy feeds as strength builds up. NB: If feeds are too strong too early, hepatomegaly and a slower recovery result.